The Six Care Practices that Support Normal Birth (Part Two)

Posted on June 25, 2009. Filed under: Birth, Cesarean, Pregnancy | Tags: , , , , , , , , , , , |

As I said in Part One of this article, there are six care practices that support normal birth. Lamaze International says “The six care practices below are supported by research studies that examine the benefits and risks of maternity care practices. Therefore, they represent “evidence-based care,” which is the gold standard for maternity care worldwide. Evidence-based care means “using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making.”

Unfortunately, in the U.S., the trend is not towards normal birth and adhering to the six care practices that support normal birth. Maternity care in the U.S. has a “prominent position, large expenditures and troubling performance” according to the Milbank report Evidence-Based Maternity Care: What It Is and What It Can Achieve released in October of 2008. This report discusses the issues with the U.S. maternity systems, the overuse of routine interventions and the harm they cause and closing the gap between them and the normal birth practices for healthier moms and babies. I will talk about this report in depth in another post as it has some great information that every pregnant woman should know.

Care Practice #1: Labor Begins on its Own

This seems so obvious but women are being induced more and more and for more and more reasons that really are not means for induction. In my Truth About Pitocin post, I discussed the difference between medical inductions and elective inductions. The medical reasons for induction are:

* your water has broken and labor has not begun.
* your pregnancy is postterm (more than 42 weeks).
* you have high blood pressure caused by your pregnancy.
* you have health problems such as diabetes that could affect your baby.
* you have an infection in the uterus.
* your baby is growing too slowly.

Suspected big baby is not reason for induction and ACOG doesn’t recommend it either but it is commonly a reason for induction. Also common to that is the birth of an 8lb baby after the induction failed and a cesarean had to be performed when if given time, the mother would have spontaneously began labor on her own when both she and the baby were ready.

Also important to note is that a pregnancy is not considered post term until AFTER 42 weeks. Only after 42 weeks should the pregnancy be induced if all else is normal.

Labor induction is not without risk. Research has shown there is a significant increase in

* vacuum or forceps-assisted vaginal birth;
* vacuum or forceps-assisted vaginal birth;
* cesarean surgery;
* problems during labor such as fever, fetal heart rate changes, and shoulder dystocia
* babies born with low birth weight;
* admission to the NICU;
* jaundice (yellow skin caused by the breaking down of red blood cells) that required treatment; and
* increased length of hospital stay.

In addition, the chance of cesarean is nearly doubled when induced and there is a higher risk of prematurity as due dates are only estimates. There are also psychological effects as it makes us think that there is something wrong with us for not going into labor on our on. I have had clients ask me if I thought a friend was capable of going into labor or if someones water can break on it’s on. These are pretty valid questions, especially for a first time mom who has seen most of her friends get induced for one reason or another and every one of them had artificial rupture of membranes (water broken for them). The thing is, our bodies will not stay pregnant forever. We are meant to birth the babies that we grow. We are just forgetting that in this day in age where most women are given pitocin and think that they just HAD to have it or they couldn’t have birthed their baby. It’s really sad that we have come to this. We do not HAVE to have pitocin to give birth.

Care Practice #2: Freedom of Movement During Labor

This one is pretty simple but too often women are told to get in the bed and stay there. Usually this happens because they are on some medication (pitocin, cytotec, anesthesia) that requires continual fetal monitoring and IV lines. All of this is counterproductive to what the body and the baby are trying to do. The uterus works better when a woman moves around. It’s a muscle and movement increases circulation. The pelvis not stationary. It moves and flexes and bends and as it does the baby is able to moved and wiggle down into it with the help of gravity. Being on the back in bed prohibits this movement and closes the pelvis up making a smaller exit for the baby to move in to.

The research has shown that movement causes:

shorter labors,
more efficient contractions
greater comfort
less need for pain medicine in labor

Even if there is a medical reason to have continual electronic fetal monitoring, there is enough slack in the line to get out of bed and sit in a chair or a birth ball or to sway with your partner.

Care Practice #3: Continuous Labor Support

I am a doula, I think every woman should have a doula. It’s not because I am trying to justify the profession or the cost or to promote myself, but I really believe that no woman should have to birth without someone who is trained to support a laboring woman. There is a big difference between a doula and a loving partner, a doula and a best friend who has had five kids and a doula and the grandma. While a doula does form a relationship with her clients, she doesn’t have that intimate relationship these other people do and can help the laboring woman without the emotions that are often involved with these family members. Doulas are also trained professionals who study birth and labor and ways to make labor easier and more comfortable with different positions and massage and other techniques that even someone who has had a few kids of their own may not know. Doctors, midwives and nurses often times have several patients at once and cannot stay with the laboring woman.

The research has shown that the presence of one-on-one support such as that of a doula a less likely to have:

have a cesarean section;
give birth with vacuum or forceps;
have regional analgesia (e.g., an epidural)
have any analgesia (pain medication)
report negative feelings about their childbirth experience

Doulas can also help incorporate the partner into the labor experience. Often times partners are very inexperienced in childbirth and they are nervous and worried and are scared of labor pains. They are often scared and unsure of how to help their partner even though they very much want to. I have found that they are relieved to have the help of a doula, especially once labor kicks in to high gear and they do feel more of a part of the labor process when they are shown ways to help the mother. It gives them a greater sense of importance and usefulness that they very much appreciate. I love working with the partners as much as the moms because they are so willing and grateful by the end. Even the strongest, most loving and supportive dads benefit from having a doula around.

There are three more care practices supporting normal birth. I will discuss them in Part Three.

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The Truth About Pitocin and Labor Induction

Posted on June 9, 2009. Filed under: pitocin, Pregnancy | Tags: , , , , , |

There is a difference between elective induction and medical induction. Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Reasons for medical induction include: fetal distress, pre-eclampsia, uterine infection, premature rupture of membranes and other situations where the health of the mother or baby are compromised by continuing the pregnancy. One in five pregnancies are induced in the U.S. with some hospitals reporting induction rates as high as 50%. The medical induction group appears to be in the minority, however, since the 1999 Green Journal review reported that as many as 3 out of 4 labor inductions were performed without an indicated risk. (I cannot link the article and it is 10 years old but I would be willing to bet the stats aren’t any better now as induction rates have increased). In short that means that 75% of induced pregnancies are not for medical reasons. Research has proven that elective inductions lead to higher c section rates.

I start this post discussing the differences between medical induction and elective induction because labor is often induced with a drug called Pitocin that is only approved for use in medical inductions. Pitocin is synthetic for of the hormone Oxytocin that the body releases to cause contractions. How does Pitocin play into the reasons for induction? Well, I am going to tell you but let’s start with some background info first.

Someone asked me the other day what the long term affects of Pitocin use where. I told her that it was unknown and I started thinking about Pitocin and everything that I know about it. Here’s what I knew…

It’s a chemical synthetic version of Oxytocin
It’s used for labor induction and postpartum hemorrhage
It causes contractions to be stronger, longer and closer together than normal, which leads to epidural use
It can hyperstimulate the uterus
It can cause fetal distress
It interferes with the normal flow of Oxytocin but does not replicate the emotional responses that Oxytocin create
It can cause uterine rupture

I decided that I should learn more about it as it is becoming more routinely used. Here’s what I found according to the package insert

In the mother it can cause:
Anaphylactic reaction
Premature ventricular contractions
Postpartum hemorrhage
Pelvic hematoma
Cardiac arrhythmia
Subarachnoid hemorrhage
Fatal afibrinogenemia
Hypertensive episodes
Nausea
Rupture of the uterus
Vomiting

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug. Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.

For the baby it can cause:
Due to induced uterine motility:
Bradycardia
Low Apgar scores at five minutes
Premature ventricular contractions and other arrhythmias
Neonatal jaundice
Permanent CNS or brain damage
Neonatal retinal hemorrhage
Fetal death
Neonatal seizures have been reported with the use of Pitocin.

These are the known short term affects of use. There have been no long term or controlled studies for long term affects. Due to this the package insert says this based on recommendations from the FDA:

IMPORTANT NOTICE

Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor.

Now THIS I didn’t know. It is not even approved for use for elective induction! How many of you had routine pitocin administered in your labor? To ‘get things going’? To ‘get you over that hump’? How many of you were informed that it’s not approved for that? How many of your were told of all the risks associated with it’s use? How many of you weren’t even told it was being administered through your required routine IV?

When you think of risk vs benefit, and you are told that your baby is safer on the outside than on the inside then Pitocin induction is a risk that may not be as risky as not inducing. That makes perfect sense to me. Why would we subject ourselves and our babies to these risks for no reason other than being tired of being pregnant? Or being told that you might have a big baby? Which by the way, ACOG doesn’t even recommend induction for suspected microsomia because growth scans can be off by up to two pounds. Another common induction reason is that the pregnancy is past 40 weeks. What happened to 42 weeks before discussing induction?

Here’s what I suggest…

Learn as much as you can about induction if it’s being suggested. Learn the medical reasons and risk vs benefits of inducing or not. Find out your Bishop’s Score. The Bishop’s Score can help you understand your chances of having successful induction or failed induction. Learn about the natural induction methods and ways to get labor going. Sex and nipple stimultion and orgasms all cause the body to release oxytocin!

The c section rate in the U.S. is horrifying. Many of these unnecesarians are due to failed inductions. I haven’t discussed c sections and their risks yet but I will go ahead and leave you with this…

According to Mardsen Wagner’s interview in The Business of Being Born, he says that section rates in the 70’s in the U.S. were at 7%. It is now over 30% and no more babies are being saved than before. In fact, the U.S. ranks 28th in the WORLD for infant mortality. That means that 27 other modern countries have better out comes than the U.S. C section has become so routine in our country that most people don’t even understand the risks involved. I truly believe that the way to start lowering these incredibly high numbers is to stop the elective inductions.

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